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Leamy M, Bird V, Le Boutillier C, Williams J, Slade M A conceptual framework for personal
recovery in mental health: systematic review and narrative synthesis, British Journal of Psychiatry,
in press.
A conceptual framework for personal recovery in mental health:
systematic review and narrative synthesis
Mary Leamy*#
Victoria Bird#
Clair Le Boutillier
Julie Williams
Mike Slade
King’s College London, Institute of Psychiatry
* Corresponding author
# Joint first author
2
Abstract
Background
No systematic review and narrative synthesis on personal recovery in mental illness has been
undertaken.
Aims
To synthesise published descriptions and models of personal recovery into an empirically-based
conceptual framework.
Method
Systematic review and modified narrative synthesis.
Results
97 papers were included from 5,208 papers identified and 366 reviewed. The emergent conceptual
framework consists of: i) thirteen Characteristics of the Recovery Journey; ii) five Recovery
Processes comprising Connectedness, Hope and optimism about the future, Identity, Meaning in
life and Empowerment (giving the acronym CHIME); and iii) Recovery Stage descriptions which
mapped onto the Transtheoretical Model of Change
1
. Studies focussed on recovery for Black and
Minority Ethnic (BME) individuals showed a greater emphasis on Spirituality and Stigma and also
identified two additional themes: Culturally specific facilitating factors and Collectivist notions of
recovery.
3
Conclusions
The conceptual framework is a theoretically-defensible and robust synthesis of people’s
experiences of recovery in mental illness. This provides an empirical basis for future recovery-
oriented research and practice.
Declaration of interest
None.
4
Introduction
Personal recovery has been defined as “a deeply personal, unique process of changing one’s
attitudes, values, feelings, goals, skills and/or roles…a way of living a satisfying, hopeful and
contributing life even with the limitations caused by illness”
2
. A recovery orientation is mental
health policy in most Anglophone countries. For example, the mental health plan for England
2009-2019 has the “expectation that services to treat and care for people with mental health
problems will be…based on the best available evidence and focused on recovery, as defined in
discussion with the service user”
3
. The implications of a recovery orientation for working practice
are unclear, and guidelines for developing recovery-orientated services are only recently becoming
available
4;5
. Comprehensive reviews of the recovery literature have concluded that there is a need
for conceptual clarity on recovery
6;7
. Current approaches to understanding personal recovery are
primarily based on qualitative research
8
or consensus methods
9
. No systematic review and
synthesis of personal recovery in mental illness has been undertaken.
The aims of this study were (i) to undertake the first systematic review of the available literature
on personal recovery and (ii) to use a modified narrative synthesis to develop a new conceptual
framework for recovery. A conceptual framework, defined as “a network, or a plane, of interlinked
concepts that together provide a comprehensive understanding of a phenomenon or phenomena”
10
,
provides an empirical basis for future recovery-oriented research and practice.
Method
Eligibility criteria
The review sought to identify papers that explicitly described or developed a conceptualisation of
personal recovery from mental illness. A conceptualisation of recovery was defined as either a
visual or narrative model of recovery, or themes of recovery, which emerged from a synthesis of
5
secondary data or an analysis of primary data. Inclusion criteria for studies were: (i) contains a
conceptualisation of personal recovery from which a succinct summary could be extracted; (ii)
presented an original model or framework of recovery; (iii) was based on either secondary research
synthesising the available literature or primary research involving quantitative or qualitative data
based on at least three participants; (iv) was available in printed or downloadable form; (v) was
available in English. Exclusion criteria were: (a) studies solely focussing upon clinical recovery
5
(i.e. using a predefined and invariant ‘getting back to normal’ definition of recovery through
symptom remission and restoration of functioning); (b) studies involving modelling of predictors
of clinical recovery; (c) studies defining remission criteria or recovery from substance misuse,
addiction or eating disorders; and (d) dissertations and doctoral theses (due to article availability).
Search strategy and data sources
Three search strategies were used to identify relevant studies: electronic database searching, hand
searching and web based searching.
1. Twelve bibliographic databases were initially searched using three different interfaces: AMED;
British Nursing index; EMBASE; MEDLINE; PsycINFO; Social Science Policy (accessed via
OVID SP); CINAHL; International Bibliography of Social Science (accessed via EBSCOhost
and ASSIA); British Humanities Index; Sociological abstracts; and Social Services abstracts
(accessed via CSA Illumina). All databases were searched from inception to September 2009
using the following terms identified from the title, abstract, key words or medical subject
headings: ( ‘mental health’ OR ‘mental illness$’ OR ‘mental disorder’ OR mental disease’ OR
‘mental problem’) AND ‘recover$’ AND (‘theor$’, OR ‘framework’, OR ‘model’, OR
‘dimension’, OR ‘paradigm’ OR ‘concept$’). The search was adapted for the individual
databases and interfaces as needed. For example, CSA Illumina only allows the combination of
6
three ‘units’ each made up of three search terms at any one time e.g. (‘mental health’ OR
‘mental illness*’ OR ‘mental disorder’) AND ‘recover*’ AND (‘theor$’ OR ‘framework’ OR
‘concept’). As a sensitivity check, ten papers were identified by the research team as highly
influential, based on number of times cited and credibility of the authors (included papers 3, 9,
10, 19, 29, 34, 35, 40, 68 and 75 in Online Data Supplement 1). These papers were assessed for
additional terms, subject headings and key words, with the aim of identifying relevant papers
not retrieved using the original search strategy. This led to the use of the following additional
search terms: (‘psychol$ health’ OR ‘psychol$ illness$’ OR ‘psychol$ disorder’ OR psychol$
problem’ OR ‘psychiatr$ health’, OR psychiatr$ illness$’ OR ‘psychiatr$ disorder’ OR
‘psychiatr$ problem’) AND ‘recover$’ AND (‘theme$’ OR ‘stages’ OR ‘processes’).
Duplicate articles were removed within the original database interfaces using Reference
Manager Software Version 11.
2. The table of contents of journals which published key articles (Psychiatric Rehabilitation
Journal, British Journal of Psychiatry and American Journal of Psychiatry) and recent literature
reviews of recovery (included papers 4, 37 and 89 in Online Data Supplement 1) were hand-
searched.
3. Web-based resources were identified by internet searches using Google and Google Scholar
and through searching specific recovery-orientated websites (Scottish Recovery Network:
www.scottishrecovery.net; Boston University Repository of Recovery Resources:
www.bu.edu/cpr/repository/index.html; Recovery Devon: www.recoverydevon.co.uk; and
Social Perspectives Network: www.spn.org.uk).
Data Extraction and Quality Assessment
One rater (VB) extracted data and assessed the eligibility criteria for all retrieved papers with a
random sub-sample of 88 papers independently rated by a second rater (JW or CL). Disagreements
7
between raters were resolved by a third rater (ML). Acceptable concordance was predefined as
agreement on at least 90% of ratings. A concordance of 91% agreement was achieved. Data were
extracted and tabulated for all papers rated as eligible for the review.
Included qualitative papers were initially quality assessed by three raters (VB, JW and CL) using
the RATS qualitative research review guidelines
11
. The RATS scale comprises 25 questions about
the relevance of the study question, appropriateness of qualitative method, transparency of
procedures, and soundness of interpretive approach. In order to make judgements about quality of
papers, we dichotomised each question to yes (1 point) or no (0 points), giving a scale ranging
from 0 (poor quality) to 25 (high quality). A random sub-sample of 10 qualitative studies were
independently rated using the RATS guidelines by a second rater (ML). The mean score from
rating 1 was 14.8 and from rating 2 was 15.1, with a mean difference in ratings of 0.3 indicating
acceptable concordance. The Effective Public Health Practice Project (EPHPP)
12
quality
assessment tool for quantitative studies was used to rate the two quantitative studies. Independent
ratings were made by two reviewers (VB, ML) of Ellis and King
13
and Resnick and colleagues
14
,
who agreed on rating both papers as moderate.
Data Analysis
The conceptual framework was developed using a modified narrative synthesis approach
15
. The
three stages of the narrative synthesis comprised: 1) Developing a preliminary synthesis; 2)
Exploring relationships within and between studies; and 3) Assessing the robustness of the
synthesis. For clarity, the development of the conceptual framework (Stages 1 and 3) is presented
in the Results before the sub-group comparison (Stage 2).
8
Stage 1: Developing a preliminary synthesis
A preliminary synthesis was developed using tabulation, translating data through thematic analysis
of good quality primary data, and vote counting of emergent themes. For each included paper, the
following data were extracted and tabulated: type of paper, methodological approach, participant
information and inclusion criteria, study location, and summary of main study findings. An initial
coding framework was developed and used to thematically analyse a sub-sample of qualitative
research studies with the highest RATS quality rating (i.e. RATS score of 15 or above), using
NVIVO QSR International qualitative analysis software (Version 8). The main over-arching
themes and related sub-themes occurring across the tabulated data were identified, using inductive,
open coding techniques. Additional codes were created by all analysts where needed and these new
codes were regularly merged with the NVIVO master copy and then this copy was shared with
other analysts, so all new codes were applied to the entire sub-sample.
Finally, once the themes had been created, vote counting was used to identify the frequency with
which themes appeared in all of the 97 included papers. The vote count for each category
comprised the number of papers mentioning either the category itself or a subordinate category. On
completion of the thematic analysis and vote counting, the draft conceptual framework was
discussed and refined by all authors. Some new categories were created, and others were subsumed
within existing categories, given less prominence or deleted. This process produced the
preliminary conceptual framework.
Stage 2: Exploring relationships within and between studies
Papers were identified from the full review which reported data from people from Black and
Minority Ethnic (BME) backgrounds. These papers were thematically analysed separately, and the
emergent themes compared to the preliminary conceptual framework. The thematic analysis
9
utilised a more fine-grained approach, in which a 2nd analyst (VB) went through the papers in a
detailed and line-by-line manner. The aim of the sub-group analysis was to specifically identify
any additional themes as well as any difference in emphasis placed on areas of the preliminary
framework. The aim was to identify areas of different emphasis in this sub-group of studies, rather
than being a validity check.
Stage 3: Assessing robustness of the synthesis
Two approaches were used to assess the robustness of the synthesis. First, qualitative studies
which were rated as moderate quality on the RATS scale (i.e. RATS score of 14) were
thematically analysed until category saturation was achieved. The resulting themes were then
compared with the preliminary conceptual framework developed in Stages 1 & 2. Second, the
preliminary conceptual framework was sent to an expert consultation panel. The panel comprised
54 advisory committee members of the REFOCUS Programme (see researchintorecovery.com for
further details) who had either academic, clinical or personal expertise about recovery. They were
asked to comment on the positioning of concepts within different hierarchical levels of the
conceptual framework, identify any important areas of recovery which they felt had been omitted
and make any general observations. The preliminary conceptual framework was modified in
response to these comments, to produce the final conceptual framework.
Results
The flow diagram for the 97 included papers is shown in Figure 1.
Insert Figure 1 here
The 97 included papers are shown in Online Data Supplement 1.
10
Insert Online Data Supplement 1 here
The 97 papers comprised qualitative studies (n=37), narrative literature reviews (n=20), book
chapters (n=7), consultation documents reporting the use of consensus methods (n=5), opinion
pieces or editorials (n=5), quantitative studies (n=2), combining of a narrative literature review
with personal opinion or where there is insufficient information on method for a judgement to be
made (n=11), and elaborations of other identified papers (n=10). In summary, 87 distinct studies
were identified. The ten elaborating papers were included in the thematic analysis but not the vote
counting (included papers 11, 15, 16, 19, 26, 48, 50, 53, 71 and 73 shown in Online Data
Supplement 1).
The 97 papers described studies conducted in 13 countries, including the United States of America
(n=50), United Kingdom (n=20), Australia (n=8) and Canada (n=6). Participants were recruited
from a range of settings including community mental health teams and facilities, self help groups,
consumer-operated mental health services and supported housing facilities. The majority of studies
used inclusion criteria that covered any diagnosis of severe mental illness. A few studies only
included participants who had been diagnosed with a specific mental illness (e.g. schizophrenia,
depression). The sample sizes in qualitative data papers ranged from 4 to 90 participants, with a
mean sample size of 27. The sample sizes in the two quantitative papers were 19 (pilot study of 15
service users and 4 case managers using a recovery interventions questionnaire
13
) and 1,076
(representative survey of people with schizophrenia
14
). The former was a pilot study of 15 service
users with experience of psychotic illness and 4 case managers using a Recovery Interventions
Questionnaire, carried out in Australia. The latter study analysed data from two sources, the
Schizophrenia Patient Outcomes Research Team (PORT) client survey, which examined usual care
11
in a random sample of people with schizophrenia in two US states and an extension to this survey
which provided a comparison group.
There were various approaches to determining the stage of recovery of participants. Most studies
rated stage of recovery using criteria such as: i) the person defined themselves as ‘being in
recovery’; ii) not hospitalised during the previous 12 months, iii) relatively well and symptom free;
iv) providing peer support to others; or v) working or living in semi-independent settings. Only a
few studies specifically used professional opinion - clinical judgement or scores on clinical
assessments - about whether people were recovered.
The mean RATS score for the 36 qualitative studies was 14.9 (range 8 to 20). One qualitative
study was not rated using the RATS guidelines because there was insufficient information on
methodology within this paper. A RATS score of 15 or above, indicating high quality was obtained
by 16 papers and used to develop a preliminary synthesis. A RATS score of 14, indicating
moderate quality, was obtained by five papers. Independent ratings were made of the two
quantitative papers, Ellis and King
13
and Resnick and colleagues
14
which were rated as moderate
by two reviewers (VB + ML). Given this quality assessment, no greater weight was put on the
quantitative studies in developing the category structure.
Conceptual framework for Personal Recovery
A preliminary conceptual framework was developed, which comprised five super-ordinate
categories: Values of recovery, Beliefs about recovery, Recovery-promoting attitudes of staff,
Constituent processes of recovery, and Stages of recovery.
12
The robustness of the synthesis underpinning the preliminary conceptual framework was assessed
in two steps; by re-analysing a sub-sample of qualitative studies and through expert consultation.
Sub-sample re-analysis
In addition to the higher quality qualitative studies analysed in the preliminary synthesis stage, an
additional five moderate quality (RATS score of 14) qualitative studies were analysed, which
confirmed that category saturation had been achieved, indicating that the categories are robust.
Expert consultation
A response was received from 23 (43%) of the 54 consulted experts with international and national
academic, clinical, and/or personal expertise and experiences of recovery, who are advisory
committee members of the REFOCUS programme into recovery. Responses were themed under
the following headings: Conceptual (dangers of reductionism, separating processes from stages,
confusing critical impetus for behaviours with actual behaviour, limitations of stage models);
Structural (complete omissions, lack or over-emphasis upon specific areas of recovery), Language
(too technical); and Bias (potential geographical bias). In response to this consultation, the
preliminary conceptual framework was simplified, so the final conceptual framework now has
three rather than five super-ordinate categories. Some sub-categories were re-positioned within
Recovery Processes, and some category headings changed. Some responses identified areas of
omission, such as the role of past trauma, hurt, and physical health in recovery. However, no
alteration was made to the conceptual framework as these did not emerge from the thematic
analysis. Other points around the strengths and limitations of the framework are addressed in the
Discussion. Overall, the expert consultation process provided a validity check on content of
conceptual framework, whilst we were careful to not to make radical changes which would have
13
been unjustified, given the weight of evidence provided from preliminary analysis of the included
papers.
The final conceptual framework comprises three inter-linked, super-ordinate categories:
Characteristics of the Recovery Journey; Recovery Processes; and Recovery Stages.
Characteristics of the Recovery Journey were identified in all 87 studies, and vote-counting was
used to indicate their frequency, shown in Table 1.
Insert Table 1 here
The categories of Recovery Processes and their vote counts, indicating frequency of the process
being identified, for the two highest category levels are shown in Table 2.
Insert Table 2 here
The full description of Recovery Processes categories and the vote counting results are shown in
Online Data Supplement 2.
Insert Online Data Supplement 2 here
Fifteen studies developed Recovery Stage models. The studies were organised using the
Transtheoretical Model of Change
1
, as shown in Table 3.
Insert Table 3 here
14
Recovery in Black and Minority Ethnic (BME) individuals
As part of stage two of the narrative synthesis process, six studies of recovery from the perspective
of BME individuals were identified within the 87 studies. These six studies were re-analysed by a
second analyst (VB), using a more fine-grained, line-by-line approach to thematic analysis. These
comprised a survey of 50 recipients of a community development project in Scotland
16
, a
qualitative interview study of African-Americans
17
, a narrative literature review
18
, a qualitative
study of 40 Maori and non-Maori New Zealanders
19
, a pilot study to test whether the Recovery
Star measure was applicable to Black and Asian Ethnic Minority population
20
and a mixed method
study of 91 males from African-Caribbean backgrounds
21
. These papers provide some preliminary
insights into a small number of distinct ethnic minority perspectives, which do not represent a
culturally homogenous group, although some similarities in experience can be observed. Although
these six papers were included in the vote counting process, four of the six BME papers
16-18;20
were
not used in the first stage thematic analysis. The line-by-line secondary analysis allowed us to
explore in greater detail any differences in emphasis and additional themes present in these papers.
The main finding of the sub-group analysis indicated that there was substantial similarity between
studies focussing on minority communities and those focussing on majority populations. All of the
themes of the conceptual framework were present in all six of the BME papers. Despite this overall
similarity, there was a greater emphasis in the BME papers on two areas in the Recovery
Processes: Spirituality and Stigma; and two additional categories: Culturally specific factors; and
Collectivist notions of recovery.
15
In relation to Spirituality, being part of a faith community and having a religious affiliation was
seen as an important component of an individual’s recovery. People from ethnic minorities more
often described spirituality in terms of religion and a belief in God as a higher power, whereas the
non-BME studies tended to conceptualise spirituality as encompassing a wider range of beliefs and
activities.
In relation to Stigma, BME studies emphasised the stigma associated with race, culture and
ethnicity, in addition to the stigma associated with having a mental illness. Furthermore, being an
individual from a minority ethnic group seemed to accentuate the stigma of mental illness, as the
person often viewed themselves as belonging to multiple stigmatised and disadvantaged groups.
Individuals from ethnic minorities saw themselves as recovering from racial discrimination, stigma
and violence, and not just from a period of mental illness.
The new category of Culturally specific factors included the use of traditional therapies, faith
healers and belonging to a particular cultural group or community. Finally, collectivist notions of
recovery were emphasised as both positive and negative factors. Many individuals discussed the
hope and support they received from their collectivist identity, but for others the community added
to the pressures of mental illness. This was particularly true where communities lacked
information and awareness regarding mental illness. Furthermore, the negative impact of the
community was felt not only at the level of the individual, but also at the collectivist level, with the
whole family being adversely affected by stigma.
Discussion
This is the first systematic review and narrative synthesis of personal recovery. A conceptual
framework was developed using a narrative synthesis which identified three super-ordinate
16
categories: Characteristics of the Recovery Journey, Recovery Processes and Recovery Stages. For
each super-ordinate category, key dimensions were synthesised. The Recovery Processes, which
have the most proximal relevance to clinical research and practice, can be summarised using the
acronym CHIME. The robustness of the category structure was enhanced by the systematic nature
of the review, the quality assessment of included studies, the category saturation reached in the
analysis, and the content validity of the expert consultation. Heterogeneity between studies was
explored descriptively. A sub-group comparison between the experiences of recovery from the
perspective of BME individuals identified similar themes, with a greater emphasis on Spirituality
and, Stigma, and two additional themes: Culturally specific factors, and Collectivist notions of
recovery.
Implications for research and practice
Key knowledge gaps have been identified as the need for clarity about the underpinning
philosophy of recovery
22
, better understanding of the stages and processes of recovery
6
, and valid
measurement tools
23
. This study can inform each of these gaps.
Recovery has been conceptualised as a vision, a philosophy, a process, an attitude, a life
orientation, an outcome and a set of outcomes
6
. This has led to the concern that “its scope can
make a cow-catcher on the front of a road train look discriminating”
24
. An empirically-based
conceptual framework can bring some order to this potential chaos. Characteristics of the
Recovery Journey provide conceptual clarity about the philosophy. Recovery Processes can be
understood as measurable dimensions of change which typically occur during recovery, and
provide a taxonomy of recovery outcomes
25
. Finally, Recovery Stages provide a framework for
guiding stage-specific clinical interventions and evaluation strategies.
17
The framework contributes to understanding about stages and processes of recovery in two ways.
First, it allows available evidence to be more easily identified. A recovery orientation has overlap
with the literature on well-being
26
, positive psychology
27
and self-management
28
, and systematic
reviewing is hampered by the absence of relevant MeSH (Medical Sub-Headings) headings
relating to recovery concepts. The coding framework provides key-words for use when
undertaking secondary research, and the identification of related terms provides a taxonomy which
will be useable in reviews.
Second, the framework provides a structure around which research and clinical efforts can be
oriented. The relative contribution of each Recovery Process, investigating interventions which can
support these processes, and the synchrony between recovery processes and stages are all testable
research questions. For clinical practice, the CHIME recovery processes support reflective
practice. If the goal of mental health professionals is to support recovery then one possible way
forward is for each working practice to be evaluated in relation to its impact on these processes.
This has the potential to contribute to current debates about recovery and, for example, assertive
outreach
29
, risk
30
and community psychiatry
31
.
Finally, the conceptual framework can contribute to the development of measures of personal
recovery. Compendia of existing measures have been developed
32;33
, showing that the conceptual
basis of measures is diverse. The conceptual framework provides a foundation for developing
standardised recovery measures, and is the basis for a new measure currently being developed by
the authors to evaluate the contribution of mental health services to an individual’s recovery. The
challenge will then be to incorporate a focus on recovery outcomes, and associated concepts such
as well-being
27
, into routine clinical practice
34
.
18
Limitations
The study has three methodological and two conceptual limitations. The first methodological
limitation is that the narrative synthesis approach was modified, and could have been widened. For
example, the exploration in Stage 2 of relationships between studies could have considered the
sub-group of studies which had higher levels of consumer involvement in their design, but it
proved impossible to reliably rate identified studies in this dimension. The second technical
limitation is that the emergent categories were only one way of grouping the findings, and the
categories changed as a result of expert consultation. In particular, the three super-ordinate
categories are not separate, since processes clearly occur within the identified stages, and the
characteristics of recovery describe an overall movement through stages of recovery. Our
categorical separation brings structure, but a replication study may not arrive at the same overall
thematic structure. The final technical limitation is that analysis synthesised the interpretation in
the paper of the primary data in each paper, rather than considering the primary data directly.
Future research could compare papers generated by different stakeholder groups, such as consumer
researchers, clinical researchers, and policy-makers.
The first conceptual limitation is that this review, whilst synthesising the current literature on
personal recovery, should not be seen as definitive. A key scientific challenge is that the
philosophy of recovery gives primacy to individual experience and meaning (‘idiographic’
knowledge), whereas mental health systems and current dominant scientific paradigms give
prominence to group-level aggregated data (‘nomothetic’ knowledge)
5
. The practical impact is that
current recovery research is primarily focussed at the bottom of the hierarchy of evidence
35
. This
was our finding, with qualitative, case study and expert opinion methodologies dominating. A
motivator for the current study was to provide evidence of the form viewed as high quality within
the current scientific paradigm, but several of our expert consultants highlighted the dangers of
19
closing down discourse. Since recovery is individual, idiosyncratic and complex, this review is not
intended to be a rigid model of what recovery ‘is’. Rather, it is better understood as a resource to
inform future research and clinical practice. The second conceptual limitation relates to the sub-
group analysis looking at papers focusing on non-majority populations. Due to a lack of research,
it was not possible to look at the experience and perspectives of individuals from different minority
groups. Therefore, the BME sub-group represents a heterogeneous and incredibly diverse set of
populations. However, it was felt that all the populations included in these papers, shared a
common experience of belonging to minority ethnic group, and that this experience may have
important implications to the meaning of personal recovery, and to the experience of mental health
services in general. The lack of data coupled with the areas of difference found in the present
review, highlights a need for further work to be conducted with people from minority ethnic
communities.
Future research
This systematic review and narrative synthesis has highlighted the dominance of recovery
literature emanating from USA. Culturally, the USA neglects character strengths such as patient
and tolerance
36
, and favours individualistic over collectivist understandings of identity. Although
there were very few studies which looked at recovery experiences of individuals from BME
backgrounds, the sub-sample of BME studies indicated that there are important differences in
emphasis. There is a need for research to be conducted using a more diverse samples of people
from different ethnic and cultural backgrounds, at differing stages of recovery and experiencing
different types of mental illness.
The complexity of personal recovery requires a range of theoretical inquiry positions. This review
focussed on research into first-person accounts of recovery, where individual meanings of recovery
20
have dominated. This has led to a framework which may under-emphasise the importance of the
wider socio-environmental context, including important aspects such as stigma and discrimination.
Viewing recovery within an ecological framework, as suggested by Onken and colleague
35
,
encompasses an individual’s life context (characteristics of the individual, such as hope and
identity) as well as environmental factors (such as opportunities for employment and community
integration) and the interaction between the two (such as choice). A more complete understanding
of recovery requires greater attention to all these levels of understanding, for instance, upon how
power is related to characteristics of individuals or groups (e.g. race and culture), how clinicians
and patients interact within different stages of recovery and how these interactions change over
time. There is also a need for future research to increase our understanding of how subtle micro-
processes of recovery are operating, such as how hope is reawakened and sustained.
Supporting Recovery Processes may be the future mental health research priority. The 13
dimensions identified as Characteristics of the Recovery Journey capture much of the experience
and complexities of recovery, and further research may not have a high scientific pay-off.
Similarly, although the Recovery Stages could be mapped onto the Transtheoretical Model of
Change
1
, there was little consensus about the number of recovery phases. It may therefore be more
helpful to undertake evaluative research addressing specific service-level questions (such as
whether people using a service are making recovery gains over time
37
or in different service
settings
38
), rather than further studies seeking conceptual clarity. Overall, the emergent priority is
the development and evaluation of interventions to support the five CHIME Recovery Processes.
The subordinate categories point to the need for a greater emphasis on assessment of strengths and
support for self-narrative development, a new construction of the contribution of the mental health
system being as much about developing inclusive communities and enabling access to peer support
as providing treatments, and clinical interaction styles which promote empowerment and self-
21
management. The CHIME categories are potential clinical end-points for interventions, in contrast
with the current dominance of clinical recovery end-points such as symptomatology or
hospitalisation rates. They also provide a framework for empirical investigation of the relationship
between recovery outcomes, using methodologies developed in relation to clinical outcomes
39
.
This area of enquiry is currently small
40
but an important priority if potential trade-offs between
desirable outcomes are to be identified
41
.
Orienting mental health services towards recovery will involve system transformation
42
. The
research challenge is to develop an evidence base which simultaneously helps mental health
professionals to support recovery and respects the understanding that recovery is a unique and
individual experience rather than something the mental health system does to a person. This
conceptual framework for personal recovery, which has been developed through a systematic
review and narrative synthesis, provides a useful starting point for meeting this challenge.
Acknowledgements
This study was funded by a National Institute for Health Research (NIHR) Programme Grant for
Applied Research (RP-PG-0707-10040) awarded to the South London and Maudsley NHS
Foundation Trust, and in relation to the NIHR Specialist Mental Health Biomedical Research
Centre at the Institute of Psychiatry, King’s College London. The views expressed in this
publication are those of the authors and not necessarily those of the NHS, the NIHR or the
Department of Health. We would also like to acknowledge Popay et al. for giving us the
unpublished guidance on narrative synthesis.
22
References
(1) Prochaska JO, DiClemente CC. Transtheoretical therapy: Toward a more integrative model
of change. Psychotherapy: Theory, Research and Practice 1982; 19:276-288.
(2) Anthony WA. Recovery from mental illness: the guiding vision of the mental health system
in the 1990s. Innovations and Research 1993; 2:17-24.
(3) HM Government. New Horizons. A shared vision for mental health. London: Department
of Health; 2009.
(4) Davidson L, Tondora J, Lawless MS, O'Connell M, Rowe M. A Practical Guide to
Recovery-Oriented Practice Tools for Transforming Mental Health Care. Oxford: Oxford
University Press; 2009.
(5) Slade M. Personal recovery and mental illness. A guide for mental health professionals.
Cambridge: Cambridge University Press; 2009.
(6) Silverstein SM, Bellack A. A scientific agenda for the concept of recovery as it applies to
schizophrenia. Clinical Psychology Review 2008; 28:1108-1124.
(7) Warner R. Recovery from schizophrenia and the recovery model. Current Opinion in
Psychiatry 2009; 22:374-380.
(8) Davidson L, Schmutte T, Dinzeo T, Andres-Hyman R. Remission and Recovery in
Schizophrenia: Practitioner and Patient Perspectives. Schizophrenia Bulletin 2008; 34(1):5-
8.
(9) Substance Abuse and Mental Health Services Administration. National Consensus
Conference on Mental Health Recovery and Systems Transformation. Rockville, MD:
Department of Health and Human Services; 2005.
(10) Jabareen Y. Building a Conceptual Framework: Philosophy, Definitions, and Procedure.
International Journal of Qualitative Methods 2009; 8:49-62.
(11) Clark J. How to peer review a qualitative manuscript. In: Godlee F, Jefferson T, editors.
Peer review in health sciences. 2nd ed. London: BMJ Books; 2003. 219-235.
(12) Effective Public Health Practice Project. Retrieved from www.ephpp.ca/index.html: 1998.
(13) Ellis G, King R. Recovery focused interventions: Perceptions of mental health consumers
and their case managers. Australian e-journal for the Advancement of Mental Health 2003;
2.
(14) Resnick SG, Fontana A, Lehman A, Rosenheck RA. An empirical conceptualization of the
recovery orientation. Schizophrenia Research 2005; 75:119-128.
(15) Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M et al. Guidance on the
conduct of narrative synthesis in systematic reviews. Results of an ESRC funded research
project. (Unpublished report). Lancaster: University of Lancaster; 2006.
23
(16) NHS Scotland. Finding strength from within, A report on three local projects looking at
mental health and recovery with people from some of the black and minority ethnic
communities in Edinburgh. 2008.
(17) Armour R, Bradshaw W, Roseborough D. African Americans and recovery from severe
mental illness. Social Work in Mental Health 2009; 7:602-622.
(18) Nicholls V. Feeding the flowers: SPN perspective on recovery. London: Social
Perspectives Network; 2007.
(19) Lapsley H, Nikora LW, Black R. Kia Mauri Tau! Narratives of Recovery from Disabling
Mental Health Problems. Wellington: Mental Health Commission; 2002.
(20) Mental Health Providers Forum. The recovery star model and culturally competency.
London: Mental Health Providers Forum; 2009.
(21) Brown M, Essien P, Etim-Ubah P. Report of the community led research project focussing
on male African and African Caribbean perspectives on recover. London: Fanon Southside
Partnership; 2008.
(22) Dinniss S, Dinn. Recovery-oriented mental healthcare. British Journal of Psychiatry 2006;
189:384.
(23) Care Services Improvement Partnership, Royal College of Psychiatrists, Social Care
Institute for Excellence. A common purpose: Recovery in future mental health services.
Leeds: CSIP; 2007.
(24) Brunskill D. From patient to service user. British Journal of Psychiatry 2010; 196:353.
(25) Slade M. What outcomes to measure in routine mental health services, and how to assess
them: a systematic review. Australian & New Zealand Journal of Psychiatry 2002; 36(6):-
743-753.
(26) Hanlon P, Carlisle S. What can the science of well-being tell the discipline of psychiatry –
and why might psychiatry listen? Advances in Psychiatric Treatment 2008; 14:312-219.
(27) Slade M. Mental illness and well-being: the central importance of positive psychology and
recovery approaches. BMC Health Services Research 2010; 26.
(28) Sterling EW, von Esenwein SA, Tucker S, Fricks L, Druss BG. Integrating Wellness,
Recovery, and Self-management for Mental Health Consumers. Community Mental Health
Journal 2010; 46:130-138.
(29) Drake RE, Deegan P. Are Assertive Community Treatment and Recovery Compatible?
Community Mental Health Journal 2008; 44:75-77.
(30) Young AT, Green CA, Estroff SE. New Endeavors, Risk Taking, and Personal Growth in
the Recovery Process: Findings From the STARS Study. Psychiatric Services 2008;
59:1430-1436.
(31) Rosen A. The Community Psychiatrist of the Future. Current Opinion in Psychiatry 2006;
19:380-388.
24
(32) Campbell-Orde T, Chamberlin J, Carpenter J, Leff SH. Measuring the Promise: A
Compendium of Recovery Measures. Vol II. Cambridge, MA: Human Services Research
Institute; 2005.
(33) National Institute for Mental Health in England. Outcomes compendium. Birmingham:
NIMHE; 2008.
(34) Slade M. Routine outcome assessment in mental health services. Psychol Med 2002;
32(8):1339-1343.
(35) Onken SJ, Craig CM, Ridgway P, Ralph RO, Cook JA. An analysis of the Definitions and
Elements of Recovery: A Review of the Literature. Psychiatric Rehabilitation Journal
2007; 31:9-22.
(36) Henry J. Positive Psychology and the Development of Well-being. In: Haworth J, Hart G,
editors. Well-being: individual, community and societal perspectives. Basingstoke:
Palgrave Macmillan; 2007. 25-40.
(37) Miller L, Brown TT, Pilon D, Scheffler RM, Davis M. Patterns of Recovery from Severe
Mental Illness: A Pilot Study of Outcomes. Community Mental Health Journal 2010;
46:177-187.
(38) Johnson S, Gilburt H, Lloyd-Evans B, Osborn D, Leese M. Inpatient and residential
alternatives to standard acute wards in England. B 2009; 194:456-463.
(39) Salvi G, Leese M, Slade M. Routine use of mental health outcome assessments: choosing
the measure. Br J Psychiatry 2005; 186:146-152.
(40) Andresen R, Caputi P, Oades L. Do clinical outcome measures assess consumer-defined
recovery? Psychiatry Research 2010; 177:309-317.
(41) Slade M, Hayward M. Recovery, psychosis and psychiatry: research is better than rhetoric.
Acta Psychiatr Scand 2007; 116(2):81-83.
(42) Shepherd G, Boardman J, Burns M. Implementing Recovery. A methodology for
organisation change. London: Sainsbury Centre for Mental Health; 2010.
25
Figure 1: Flow chart to show assessment of eligibility of identified studies
Identified papers n=5,208
Electronic databases (after duplicates removed) 5,169
Additional papers identified from hand searching, web-based
articles and citations 39
Excluded from title n = 4,389
Clearly not relevant (n = 4,085)
Population (n = 239)
Not in English (n = 65)
Abstracts review n = 819
Full papers retrieved n = 366
Excluded based on abstract n=443
Included n = 97
Excluded based on paper n=269
No succinct model or
conceptualisation (n=118)
Uses an existing model (n= 110)
Not relevant (n=24)
Population (n= 9)
Focus on clinical recovery (n= 8)
26
Table 1: Characteristics of the Recovery Journey
Dimension Number (%) of 87 studies
identifying the dimension
Recovery is an active process 44 (50%)
Individual and unique process 25 (29%)
Non-linear process 21 (24%)
Recovery as a journey 17 (20%)
Recovery as stages or phases 15 (17%)
Recovery as a struggle 14 (16%)
Multi-dimensional process 13 (15%)
Recovery is a gradual process 13 (15%)
Recovery as a life-changing experience 11 (13%)
Recovery without cure 9 (10%)
Recovery is aided by supportive and healing environment 6 (7%)
Recovery can occur without professional intervention 6 (7%)
Trial and error process 6 (7%)
27
Table 2. Recovery Processes
Recovery Processes Number (%) of 87 studies
identifying the process
Category 1: Connectedness
75 (86%)
Peer support and support groups
39 (45%)
Relationships
33 (38%)
Support from others
53 (61%)
Being part of the community
35 (40%)
Category 2: Hope and optimism about the future
69 (79%)
Belief in possibility of recovery
30 (34%)
Motivation to change
Hope inspiring relationships 15 (17%)
12 (14%)
Positive thinking and valuing success
10 (11%)
Having dreams and aspirations
7 (8%)
Category 3: Identity
65 (75%)
Dimensions of identity
8 (9%)
Rebuilding/redefining positive sense of identity
57 (66%)
Over-coming stigma 40 (46%)
Category 4: Meaning in life
59 (66%)
Meaning of mental illness experiences
30 (34%)
Spirituality
6 (41%)
Quality of life
Meaningful life and social roles
Meaningful life and social goals
57 (65%)
40 (46%)
15 (17%)
Rebuilding life
19 (22%)
Category 5: Empowerment
79 (91%)
Personal responsibility
79 (91%)
Control over life
78 (90%)
Focussing upon strengths
14 (16%)
28
Table 3: Recovery stages mapped on to Transtheoretical Model of Change
Online Data
Supplement
Study
Number
Precontemplation Contemplation Preparation Action Maintenance &
growth
32 Novitiate recovery:
Struggling with
disability
Semi-recovery –
living with
disability
Full recovery – living
beyond disability
73 Stuck Accepting help Believing Learning Self-reliant
3 Descent into hell Igniting a spark of
hope Developing
insight/
Activating
instinct to fight
back
Discovering keys
to well-being Maintaining
equilibrium between
internal and external
forces
44 Demoralisation Developing &
establishing
independence
Efforts towards
community
integration
36 Occupational
dependence Supported
occupational
performance
Active engagement
in meaningful
occupations
Successful
occupational
performance
14 Dependent/unaware Dependent/aware Independent/aware Interdependent/aware
29 Moratorium Awareness Preparation Rebuilding Growth
78 Glimpses of
recovery Turning points Road to recovery
61
Reawakening of
hope after despair No longer
viewing self as
primarily
person with
psychiatric
disorder
Moving from
withdrawal to
engagement
Active coping rather
than passive
adjustment
40 Overwhelmed by the
disability Struggling with
the disability Living with the
disability Living beyond the
disability
35 Initiating recovery Regaining what
was lost/moving
forward
Improving quality of
life
59 Crisis (recuperation) Decision
(rebuilding
independence)
Awakening
(building healthy
interdependence)
43 Turning point Determination Self-esteem
29
Data Supplements (in separate files)
Online Data Supplement 1: Included papers (n=97)
Online Data Supplement 2: Full list of categories and vote counting for Recovery Processes
30
Author contributions
All authors contributed to the conception and design, drafting and revising the article,
and gave approval to the final version. Mike Slade is the Principal Investigator.
Author details
(Corresponding author) Mary Leamy PhD, Programme Co-ordinator
King’s College London, Health Service and Population Research Department (Box
P029), Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF
Tel: 020 7848 5095
Fax: 020 7277 1462
Email: mary.leamy@kcl.ac.uk
Mike Slade PhD PsychD
Clair Le Boutillier MSc
Julie Williams MSc
Victoria Bird BSc
All at King’s College London, Health Service and Population Research Department
(Box P029), Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5
8AF
